The Indian Psychiatric Society's draft guidelines to govern doctor-patient relationships are up for discussion online.

Acknowledging the existence of unethical relationships between doctors and patients, the Indian Psychiatric Society has framed guidelines that direct doctors not to enter into sexual or emotional relationships with their patients.

This is the first time that an association of doctors in India has come up with such advice. In the UK, the General Medical Council, which governs the registration of doctors, warns doctors against using their position to pursue sexual or inappropriate emotional relationships with their patients, or someone close to them.

Though the Hippocratic oath specifies that doctors must not get into unhealthy relationships with their patients, members of the Indian Psychiatric Society felt that specific guidelines were also required.

The draft guidelines are now up for discussion online.

“We have invited suggestions from the community on the guidelines, which will be adopted next month,” said Dr G Prasad Rao, president of the Indian Psychiatric Society.

The advice is not meant for mental health experts alone, but for the entire medical fraternity. However it will be binding on members of the Indian Psychiatric Society once the body formally adopts the guidelines.

Unethical relationship

The draft outlines the protocol doctors are expected to follow while interacting with their patients, and classifies violations into two types – sexual boundary violations and non-sexual boundary violations.

It was prepared by a task-force on boundary guidelines of the Indian Psychiatric Society along with the Bangalore Declaration Group, a team of doctors across different medical specialties in India.

“Patients tend to confide in their psychiatrists,” said Rao. “We have heard of several instances where a patient has been sexually violated by the doctor.”

Said Dr Alok Sarin, a senior psychiatrist in Delhi: “I have had patients narrating incidents where they have been victims of such violations. It can be extremely damaging for the subject of the abuse [victim].”

Dr Sunita Simon Kurpad, psychiatrist and co-chairperson of the committee that drafted the guidelines, said that sexual violations by doctors were a matter of concern. “If the offences are not reported there is a possibility that they [doctors] may become serial offenders,” said Kurpad.

A study conducted by Kurpad and her colleagues among mental health professionals in Karnataka found that sexual violations by doctors were common.

As part of the study, an anonymous postal survey on the awareness of the existence of boundary violations by doctors and therapists in India was conducted among psychiatrists and clinical psychologists practising in Karnataka. At least 33% of the 51 respondents of the survey said that they had heard of at least one allegation of a sexual-boundary violation (where the doctor had sexually abused the patient) that was investigated. However, a higher percentage of respondents (51%) revealed that they had heard of a sexual boundary violation that was not investigated.

Breach of trust

The guidelines also ask doctors not to touch patients “inappropriately in the guise of physical examination or sexual therapy, for own sexual gratification” and suggest that doctor physically examining patients keep a chaperone in the room.

A study published in the Indian Journal of Medical Ethics conducted by Kurpad and her colleagues found that 78% of physical examination of adults, and 58% such examinations of children, were not done in the presence of a chaperone.

The guidelines affirm that even consensual sexual relations between patients and doctors irretrievably changes the therapeutic nature of the doctor-patient dynamic. “Even if the patient gives consent, it cannot be classified as a true consent,” said Kurpad. “It [doctor-patient relationship] is a power imbalanced relationship.”

“It is possible that the patient might get dependent [on the doctor],” said Dr Anant Bhan, researcher, bioethics and global health. “There is a lot of interaction between doctors and patients on social media and the social lines are getting blurred.”

Non-consensual sexual contact is already punishable under the law. However, experts said that not all cases are reported to the police.

“On several occasions, we have seen that the patient as well as the family member is not keen to complain,” said Rao. “With these guidelines, they can consider complaining to the [Indian Psychiatric] Society which might be an easier mechanism.”

The document also lays down when it would be appropriate for the doctor and patient to enter into a relationship.

The draft guidelines read: “A minimum time frame of one year should elapse after the doctor-patient relationship is terminated after which it may be permissible for the doctor to enter into a relationship with the patient (so long as existing laws of the Indian Penal Code are not broken).”

After receiving feedback and incorporating any revisions, the guidelines will be adopted by the Indian Psychiatric Society in October. Any complaints of violations will then be dealt with by the society’s ethical committee.

Dr G Prasad Rao, the president of the Indian Psychiatric Society, said that other medical associations have also shown an interest in adopting the guidelines.

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